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DOI:10.4236/psych.2011.27105
This study explored the usefulness of a Thematic Apperception Test (TAT, Murray, 1943) narrative scoring
system to detect signs of autistic information processing. A total of 27 patients with an Autism Spectrum Disorder were compared to a control group (N = 67) of patients with other psychiatric disorders. As an external indirect measure of social functioning two dimensions of the Social Cognition and Object Relation Scale (SCORS;
Westen,1985) were used: Capacity for Emotional and Moral Investment in Relationships and Understanding of
Social Causality. TAT narratives were rated on the prevalence of eight phenomena, as proposed by Edrisi and
Eurelings-Bontekoe (2009). Autistic patients showed a lower level of social insight and were particularly characterized by high scores on Weak Central Coherence, Jumping to Conclusions and Difficulty with describing/
interpreting movements. Results provide preliminary support for the usefulness of the TAT scoring system, but
need to be replicated using larger samples and blind scoring.
Keywords: Autism, Thematic Apperception Test, Social Cognition, Adults
Introduction
Autism Spectrum Disorders (ASDs) are neurodevelopmental
disorders, characterized by a triad of symptoms: limited reciprocal social interactions, disordered verbal and nonverbal
communication, and restricted, repetitive behaviors or circumscribed interests (Tager-Flusberg & Caronna, 2007). The DSMIV Pervasive Developmental Disorders section includes five
different disorders: Autistic Disorder (AD), Retts disorder
(RD), Childhood Disintegrative Disorder (CDD), Aspergers
Syndrome (AS), and Pervasive Developmental Disorder Not
Otherwise Specified (PDD-NOS) (American Psychiatric Association, 2000). Patients with Autism, AS and PDD-NOS share
the feature of limited reciprocal social interactions. In addition
to this feature, patients with Autism show disordered verbal and
nonverbal communication and restricted, repetitive behaviors
or circumscribed interests. Patients with AS suffer from limited reciprocal social interactions, and show restricted, repetitive behaviors or circumscribed interests, but no deficits in
verbal or nonverbal communication. Finally, patients are diagnosed with PDD-NOS if they suffer from limited reciprocal
social interactions combined with either disordered verbal or
non verbal communication or restricted repetitive behaviors. In
addition to the DSM-IV-TR (APA, 2000) criteria, three functional criteria may be described: impaired executive functioning
(Ozonoff, South, & Provencal, 2005), weak central coherence
(Happ & Frith, 2006), and impaired theory of mind (BaronCohen, 2000; Tager-Flusberg, 2007). According to Minshew,
Sweeney, and Luna (2002), information processing is disordered in patients with ASDs. Problems occur especially in
complex information processing, involving the processes that
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Measures
The Social Cognition and Object Relation Scale (SCORS;
Westen, 1985, 1991a, 1991b) was used as an external indirect
measure of social functioning. In this study the following two
dimensions as originally described by Westen (1985) were
rated: Capacity for Emotional and Moral Investment in Relationships (EI), as a measure of affective social functioning and
Understanding of Social Causality (SOC), as a measure of cognitive social functioning. Low scores on EI reflect an egocentric and selfish attitude, high scores reflect the capacity to establish and maintain reciprocal social interactions. SOC assesses a patients capacity to understand causal relationships in
social interactions. Low scores reflect illogical causal relationships, high scores reflect understanding of causal relationships
in terms of both inner motives and external circumstances. Each
dimension is scored on a five-point rating scale, with higher
scores on EI and SOC representing higher levels of social functioning. Studies have provided considerable evidence for the
convergent and discriminant validity of the SCORS (Ackerman,
Hilsenroth, Clemence, Weatherill, & Fowler, 2001, Cramer,
1999; Peters, Hilsenroth, Eudell-Simmons, Blagys, & Handler,
2006; Porcerelli, Shahar, Blatt, Ford, & Greenlee, 2006; for a
review, see Huprich & Greenberg, 2003). Interrater reliability
of the scoring of the TAT protocols of the ASD patients (ICC
(2,2)) was .88 for EI and .96 for SOC (both excellent). ICC (2,1)
were respectively .79 and .92 (excellent; see Table 1). The TAT
protocols of the control group had already been scored on the
SCORS variables EI and SOC with good to excellent interrater
reliability (Eurelings-Bontekoe et al., 2009).
The second measure used in this study was the rating of ASD
phenomena in TAT narratives. Based on clinical experience,
Edrisi and Eurelings-Bontekoe (2009) defined and described
eight phenomena that they consider typical formal characteristics of TAT protocols of patients with ASD:
1) Weak Central Coherence, i.e. trying to understand the
meaning of the picture by concentrating on details, including
irrelevant ones, instead of utilizing the whole context. Example:
Table 1.
ICC two way random effect model, single (2,1) and average measures
(2.2) for SCORS dimensions EI and SOC and for ASD phenomena.
Variables
Single measures
Average measures
.79
.88
.92
.96
.93
.96
Ruminating
.85
.92
.91
.95
Jumping to Conclusions
.61
.76
Multiple Scenarios
.98
.99
No Social Connectedness
.85
.92
No Parallel Processes
.47
.64
.75
.86
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(2,2) were good for No Parallel Processes and excellent for the
rest of the ASD phenomena (see Table 1).
Procedure
The participants in the ASD group (N = 27) who had agreed
to participate in the study were paid a house visit by one of
several (eight) investigators. Investigators were psychologists,
test assistants, or nurses, who were qualified or instructed to
take TAT-interviews. Interviews took about one hour. The TAT
was administered using standard guidelines (Conklin & Westen,
2001), asking the patient to describe what happens, what led up
to the situation, what the outcome would be, and what the
characters would be thinking and feeling. The following six
TAT cards were administered in the same order to all ASD
patients: 1, 2, 5, 6 BM, 13 MF, and 18 BM. All narratives were
recorded on audiotape and transcribed verbatim. Sixty seven
control cases were selected. TAT pictures used in this group
were 1, 2, 13 MF, 4, 3 BM, 7 GF.
The TAT protocols of the control group had already been
scored on the SCORS variables EI and SOC. The second author
scored the protocols of the ASD patients for EI and SOC and
scored all protocols, including those of the psychiatric controls
for the occurrence of each of the eight ASD phenomena, after
having been trained by the first author. The ratings for the two
SCORS dimensions were averaged across the six TAT cards
yielding a single mean score on each dimension for each patient.
For each patient and each protocol, the frequency of occurrence of the above-mentioned ASD phenomena was counted.
Since the amount of recognizable phenomena in each story is
dependent upon the length of the protocol, protocol length was
corrected for by dividing the frequency of each ASD phenomenon per protocol by the number of words in each protocol
and by multiplying this number by 100 yielding a percentage
score for each ASD phenomenon per protocol. These percentage scores of ASD phenomena were used in the MANCOVA
and Discriminant Analysis. To be able to establish interrater
reliability for the present study, the third author independently
scored a random selection of 20 ASD protocols for the SCORS
variables SOC and EI and for the ASD phenomena. The Intraclass Correlation Coefficient, two way random effect model
(ICC; Shrout & Fleiss, 1979) was used to calculate interrater
reliability. ICCs are considered to be excellent if greater
than .74, good if ranging from .60 to .74, fair, if ranging from.
40 to .59 and poor if under .40 (Cicchetti, 1994).
Analyses
Groups were compared regarding gender and age using Chisquare statistics and t-test for independent samples respecttively. In order to investigate whether the TAT ASD phenomena were associated with social functioning as operationalized
by the two SCORS variables SOC and EI, we calculated Pearson product-moment correlations between these SCORS variables and the ASD phenomena.
MANCOVA was used in order to study the differences between ASD patients and psychiatric controls regarding mean
scores on EI and SOC, mean percentages of ASD phenomena
and the number of words per protocol with age as a covariate.
Effect sizes were calculated in terms of partial eta squared
(p2). According to conventional criteria (Cohen, 1988) a p2
of .01 is small; .06 moderate; .14 large. Cohens ds were calculated as an Effect Size (ES) measure of differences between
groups (Cohen, 1977). According to conventional criteria, d
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Results
Influence of Background Variables
Gender was evenly distributed across the two groups (2
= .18; df = 1, p = .68). The groups did however differ from each
other regarding age (t (92) = 3.75, p < .05). As a consequence,
age was taken into account as a covariate.
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Table 2.
Pearsons correlations between the SCORS variables and the ASD TAT phenomena (N = 93).
ASD Phenomena
**
.32**
Ruminating
.29**
.25*
.52**
.48**
Jumping to conclusions
.34**
.24*
Multiple scenarios
.08
.11
No social connectedness
.44**
.34**
No parallel processes
.04
.01
.40
**
.18
**
.49**
.27
.58
Note: **Correlation is significant at the .01 level (2-tailed). *Correlation is significant at the .05 level (2-tailed).
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Table 3.
(a) Standardized canonical discriminant function coefficients; (b) Pooled within-groups correlations between discriminating variables and standardized
canonical discriminant function; (c) Function at group centroids; (d) Classification of results for predicted group membership.
(a)
Variables
Function 1
.67
Multiple scenarios
.41
.41
Jumping to conclusions
.38
Ruminating
.37
(b)
Variables
Function 1
.66
.54
Jumping to conclusions
.41
Ruminating
.30
Multiple scenarios
.16
(c)
Group
Function 1
ASD group
1.80
Control group
.73
(d)
Predicted Group Membership
ASD group
Original Group
Control Group
Total
Count
Percentage
Count
Percentage
Count
Percentage
ASD
22
81.5
18.5
27
100.0
Control group
4.5
64
95.5
67
100.0
Specificity, PPP and NPP are dependent upon the base rate of
the condition in the population being tested. PPP decreases with
decreasing prevalence. Likelihood ratio plus (LR+), expressed
as sensitivity/1-specificity, was 20.25, meaning that a positive
result is 20 times as likely for those who have ASD as for those
who do not suffer from ASD. Likelihood ratio minus (LR),
expressed as specificity/1-sensitivity, was 5.05, indicating that
low scores on the ASD phenomena are five times more likely to
have come from a person who does not suffer from ASD than
from a person who suffers from ASD. These figures imply that
the odds for a false negative diagnosis are relatively greater
than the odds for a false positive diagnosis.
Discussion
This study was aimed at exploring the usefulness of a TAT
ASD scoring system, using ASD phenomena, as described by
Edrisi and Eurelings-Bontekoe (2009). As expected, ASD patients differed significantly from psychiatric controls concern-
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central coherence of TAT narratives and jumping to conclusions reflect the inability of ASD patients to see the Gestalt
of a picture and their limited insight into the fact that social
interactions may be determined by a multiplicity of inner and
outer causes. ASD patients tend to focus on one particular detail and compose the story around this detail. If this detail is
irrelevant, this may result in an incomplete of completely incorrect interpretation of the social situation. Interestingly, the
inability to describe and see movements spontaneously may
parallel the results of Holaday, Moak and Shipley (2001), who
compared Rorschach responses of 24 boys with AS, with that
of 24 boys with behavioural or emotional disorders, and who
found that the mean number of M (Movement) responses in the
protocols of boys with AS was signifycantly lower as compared
to that of the contrast group. A relatively low number of M
responses refers to impaired reasoning and impaired imagination (Holaday et al., 2001).
Specificity (96%) was somewhat higher than sensitivity
(81%). A relatively lower sensitivity than specificity increases
the probability of a false negative diagnosis, as was also shown
by the Likelihood ratio minus (LR). On the other hand, a high
specificity has the advantage of decreasing the probability of a
false positive diagnosis. In other words, the TAT scoring system has the risk of missing patients with ASS, but has a lower
risk of falsely diagnosing patients with ASS, who in fact do not
suffer from the condition. Therefore, although further assessment is always needed, this is especially so in case a patient is
clinically suspected for ASD, even if the TAT narratives do not
show the typical ASD phenomena.
Limitations
The results of this study need to be viewed in de context of
several limitations.
First, the researcher scoring the narratives was aware of
which group the stories belonged to. However, with the exception of Multiple Scenarios and No Parallel Processes, each of
the ASD phenomena and the total mean percentage of ASD
phenomena were negatively correlated with affective and cognitive aspects of social functioning as measured with the
SCORS. Moreover, the TAT protocols from the ASS patients
showed a significant lower level of emotional investment and
understanding of social causality than those of the psychiatric
controls. The TAT protocols of the 67 controls had already
been scored on SCORS variables outside the context of this
study. Furthermore the two groups did not differ from each
other regarding the two ASD phenomena Multiple Scenarios
and No Parallel Processes, precisely the phenomena that were
not associated with social functioning as measured with the
SCORS. Finally, interrater reliability was good to excellent.
Taken together, the association of the ASD phenomena and the
SCORS social cognition variables in the expected direction
tentatively suggest that the ASD phenomena as they have been
scored in the present study did tap low social cognition.
Second, although the patients with ASD were assessed by
specialized clinicians, we did not confirm the diagnoses. Third,
only a small number of ASD patients participated in the study,
which might have affected the results. Fourth, the study sample
is not fully representative of the actual population of people
with ASDs. Another limitation of the study could be that a
somewhat different set of cards was used for the control group
and the ASD group. Whereas the control group described stories for the cards 1, 2, 13 MF, 4, 3 BM and 7 GF, the ASD
group saw the cards 1, 2, 5, 6 BM, 13 MF and 18BM. Although
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Conclusion
Although the use of the TAT in the assessment of patients
who are suspected for an Autism Spectrum Disorder is rather
unconventional and novel in clinical practice, the results of this
preliminary study suggest the usefulness of a formal analysis of
TAT narratives in the assessment process among adult patients
who are suspected for Autism.
TAT narratives of patients with Autism are particularly
characterized by weak central coherence, difficulties in describing and interpreting movements, and jumping to conclusions. These information processing problems may underlie the
difficulties these patients may encounter in social interactions.
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